| ADDRESS: 805 DEVELOPMENT DR, KINGSTON, ON K7M 4W6 TEL: 613-389-8660 EMAIL: reception@davidgouettdentistry.com
# DENTAL HISTORY Your co-operation in completing this questionnaire is essential to providing you with the highest standard of dental care. All information is strictly confidential.
1. PATIENT INFORMATION
Full Legal Name | [Patient Full Name]
Street Address | [Street Address]
City | [City] | Postal Code | [Postal Code]
Date of Birth | [MM/DD/YYYY] | Home Phone | [Home Phone]
Cell Phone | [Cell Phone] | Health Card # | [Health Card Number]
GENERAL HEALTH ASSESSMENT
1. Are you having pain or discomfort at this time? RESPONSE: [Yes / No]
2. Do you feel very nervous about having dental treatment? RESPONSE: [Yes / No]
3. Have you ever had a bad experience in the dental office? RESPONSE: [Yes / No]
4. Have you been a patient in the hospital during the past two years? RESPONSE: [Yes / No]
5. Have you been under the care of a medical doctor in the past two years? RESPONSE: [Yes / No]
6. Have you taken any medicine or drugs during the past two years? RESPONSE: [Yes / No]
7. Are you allergic to (itching, rash, swelling of hands, feet or eyes) or made sick by penicillin, aspirin, codeine, or any other drug or medication? RESPONSE: [Yes / No] If yes, please list: [List of Allergies]
8. Have you ever had any excessive bleeding requiring special treatment? RESPONSE: [Yes / No]
PLEASE CIRCLE ANY OF THE FOLLOWING, WHICH YOU HAVE HAD OR HAVE AT PRESENT:
[Heart Failure], [Heart Disease/Attack], [Hay Fever], [Tuberculosis], [Heart Murmur], [Sinus Trouble], [Allergies/hives], [Thyroid Disease], [X-ray cobalt tmt], [Arthritis], [Artificial Joint], [Rheumatism], [Cortisone medicine], [Glaucoma], [Pain in Jaw Joints], [Emphysema], [Cough], [Angina Pectoris], [Asthma], [Yellow Jaundice], [Blood transfusion], [Drug addiction], [Cold sores], [Genital Herpes], [Chemotherapy], [Anemia], [Nervousness], [Psychiatric Tmt], [Sickle Cell Disease], [Aids], [Hep A B C], [High blood pressure], [Liver Disease], [Rheumatic Fever], [Congenital Heart lesions], [artificial heart valve], [Pacemaker], [Heart surgery], [Epilepsy/seizures], [Fainting/Dizziness], [Stroke], [Kidney Trouble], [Ulcers] SELECTED CONDITIONS:
• [Selected Condition 1] • [Selected Condition 2] • [Selected Condition 3] [Patient's Selected Conditions List]
PHYSICAL WELLNESS INDICATORS
9. When you walk up stairs or take a walk do you ever have to stop because of pain in our chest, shortness of breath or because you are very tired? RESPONSE: [Yes / No]
10. Do your ankles swell during the day? RESPONSE: [Yes / No]
11. Do you use more than 2 pillows to sleep? RESPONSE: [Yes / No]
12. Have you lost or gained more than 10 pounds in the past year? RESPONSE: [Yes / No]
13. Do you ever wake up from sleep short of breath? RESPONSE: [Yes / No]
14. Are you on a special diet? RESPONSE: [Yes / No]
15. Has you medical doctor ever said you have cancer or a tumor? RESPONSE: [Yes / No]
16. Do you have any disease, condition or problem not listed? RESPONSE: [Yes / No] If yes, please explain: [Explanation]
WOMEN ONLY
Are you pregnant? RESPONSE: [Yes / No]
Do you anticipate becoming pregnant? RESPONSE: [Yes / No]
DENTAL PROBLEMS / HISTORY
Are you experiencing any dental problems? RESPONSE: [Yes / No]
Date of last dental visit: [MM/DD/YYYY]
Dental cleaning frequency: [Response]
When were X-rays taken last? [Month / Year]
MEDICAL HISTORY QUESTIONS
1. Have you been seeing a dentist regularly? RESPONSE: [Yes / No]
2. Are there any growths or sore spots in your mouth? RESPONSE: [Yes / No]
3. Have you noticed any loose teeth, or have any of your teeth shifted? RESPONSE: [Yes / No]
4. Does food get caught between your teeth? RESPONSE: [Yes / No]
5. Are any of your teeth sensitive to heat, cold, sweets or pressure? RESPONSE: [Yes / No]
6. Have you been advised to take antibiotics before a dental appointment? RESPONSE: [Yes / No]
7. Do you use dental floss, proxabrush, or stimudents? RESPONSE: [Yes / No] How often: [Response]
8. How often do you brush your teeth? [Response] - Do you feel that you have bad breath? RESPONSE: [Yes / No]
9. Have you ever had one of the following? • Periodontal treatment? (treatment of the gums): [Yes / No] • Orthodontic treatment? (to straighten or realign teeth): [Yes / No] • A bite plate or any other appliance?: [Yes / No] • Your bite adjusted or teeth ground?: [Yes / No] • Oral surgery? (jaw joint, implant surgery etc): [Yes / No]
10. JAW PROBLEMS - Do you have any of the following? • Popping/clicking in your jaw joints?: [Yes / No] • Pain in your jaw joints, ear, or side of face?: [Yes / No] • Difficulty in opening or closing?: [Yes / No] • Pain when teeth are clenched?: [Yes / No] • Pain/difficulty in chewing?: [Yes / No]
11. Do you have any of the following habits? • Clenching or grinding your teeth?: [Yes / No] • Biting your cheeks or lips regularly?: [Yes / No] • Breathing through your mouth?: [Yes / No] • Hold foreign objects with your teeth?: [Yes / No]
12. Do you have any emotional concerns about having dental treatment? RESPONSE: [Yes / No]
13. Are you happy with the appearance of your teeth? RESPONSE: [Yes / No] If no, what would you like to see changed: [Response]
14. Have you ever had an upsetting experience in a dental office? RESPONSE: [Yes / No] Please describe if yes: [Response]
FINANCIAL AGREEMENT
Payment must be made the day of surgery. Our office will electronically file dental claims on your behalf if you have dental insurance.
POLICY HOLDER NAME & DOB: [Name and DOB]
INS. COMPANY: [Insurance Company]
POLICY/CONTRACT #: [Number]
CERTIFICATE: [Certificate Number]
A Charge of 200.00 for less than 48 hours' notice of cancellation appointment.
1 | I, the undersigned, understand that the information contained in the medical and dental history is important to my treatment. I certify that all of the information I have completed is correct and that I have not knowingly omitted data. Ontario has a law that protects personal health information. Dr. David Gouett and Associates maintain a strict privacy policy (for more information please ask to see the Privacy Policy). I agree that Dr. David Gouett and Associates can collect, use and disclose personal information in accordance with the privacy legislation set forth by the Province of Ontario. I give Dr. David Gouett and Associates permission to sent my dental claims electronically and confirm appointments or send referrals via email. CONSENT: [YES / NO]
2 | I assume all responsibility for fees associated with my dental treatment. Please note: A potential fee may be charged for any missed or rescheduled appointments without 2 full business days notice. CONSENT: [YES]
3 | I authorize release, to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to David Gouett Dentistry. This authorization shall continue in effect until the undersigned revokes the same.
Patient/Guardian Signature [Patient Signature Placeholder] | Date of Signature [MM/DD/YYYY]
© 2026 David Gouett Dentistry. This record is protected under PIPEDA and PHIPA legislation. Unauthorized disclosure of this clinical information is strictly prohibited.